The Importance of a Practice Protocol for Nurse Practitioners

Virginia law governing the
licensure and practice of nurse practitioners requires that they practice
under the supervision of a physician. Regulations promulgated and adopted
by the Board of Nursing and the Board of Medicine further specify that the
practice of a nurse practitioner must be “in collaboration with and under
the medical direction and supervision of a licensed physician.” The
regulations detail what these terms entail:

"Collaboration"means the
process by which a nurse practitioner, in association with a physician,
delivers health care services within the scope of practice of the nurse
practitioner's professional education and experience and with medical
direction and supervision, consistent with this chapter.

"Medical direction and supervision" means participation in the development of a written protocol including
provision for periodic review and revision; development of guidelines for
availability and ongoing communications which provide for and define
consultation among the collaborating parties and the patient; and periodic
joint evaluation of services provided, e.g., chart review, case review, and
review of patient care outcomes. Guidelines for availability shall address
at a minimum the availability of the collaborating physician proportionate
to such factors as practice setting, acuity, and geography.

You will note first that the regulations
require that health care services delivered by a nurse practitioner be
within the scope of practice of the nurse practitioner’s professional
education and experience.

Then you will note that a nurse
practitioner is required to have a written protocol. This written protocol
is a practice protocol. It is different from a clinical protocol
that specifies every action to be taken for every set of circumstances you
might encounter. Rather, it is a general document that represents the
agreements that the nurse practitioner and the supervising physician have
with regard to the nurse practitioner’s practice.

The law requires that the written
protocol have several elements:

A provision for periodic review and revision of the written protocol. This
provision should be spelled out in the written protocol Guidelines for
availability and ongoing communications which provide for and define
consultation among the collaborating parties [the physician and the nurse
practitioner] and the patient. Note that the guidelines for availability
shall address at a minimum the availability of the collaborating physician
proportionate to such factors as practice setting, acuity, and geography.

Authorization from the supervising physician to prescribe physical
therapy.

With the passage of HB-855 during the
2004 session of the General Assembly that authorizes nurse practitioners
to sign and certify various documents and forms, the written protocol also
must include “the nurse practitioner's authority for signatures,
certifications, stamps, verifications, affidavits and endorsements
provided it is:

i. in
accordance with the specialty license of the nurse practitioner and with the
scope of practice of the supervising physician;

ii. permitted
by § 54.1-2957.02 or applicable sections of the Code of Virginia; and

iii. not
in conflict with federal law or regulation.”

VCNP frequently is asked to be more
specific about how a written protocol should be worded. For example, a
nurse practitioner might ask how often should chart review be done, or how
close a supervising physician must be. These factors are not specified in
the regulations because they are dependent on a number of factors including
the type of practice, the practice setting, the experience of the nurse
practitioner, the longevity of the nurse practitioner-physician
relationship, the acuity of the patients, and a host of other variables. It
is up to the nurse practitioner and the supervising physician to determine
what is reasonable given their specific practice to ensure good quality
care.

Please notice that the written protocol
is not the same as the practice agreement required for nurse practitioners
with prescriptive authority. A nurse practitioner with prescriptive
authority must have both a written protocol and a practice agreement. A
nurse practitioner without prescriptive authority is required to have only a
written protocol.

Thus, all nurse practitioners are
required to have a written protocol that includes all of these elements to
be practicing legally. To practice without one, or without one that meets
the requirements in this definition, risks disciplinary action against both
the nurse practitioner and the supervising physician.